Author Information
Panchbudhe
Shruti*, More
Vibha**, Mali
Kimaya***, Satia
MN****.
(*
Assistant Professor, ** Assistant Professor, *** Assistant Professor, ****
Professor Department of Obstetrics and Gynecology, Seth GS Medical College & KEM
Hospital, Mumbai, India)
Abstract
We report an unusual
case of a 34 year old, infertile, woman who presented in surgery
outpatient department with abdominal distension and right shoulder pain. On
clinical examination there was suspicion of subacute intestinal obstruction,
and on evaluation with X-ray and ultrasonography, obstruction was ruled out.
An
incidental finding of liver nodule was noted on ultrasonography (USG)
which was
further confirmed on computerized tomography (CT).
CT guided
biopsy of liver nodule was suggestive of endometrioid carcinoma. Patient was
referred to gynaecological department to rule out primary focus and was
diagnosed retrospectively to have carcinoma endometrium on fractional
curettage. This is an unusual presentation of advanced carcinoma endometrium in
the third decade of life which in a normal situation is the malignancy of fifth
and sixth decades of life with the only risk factor of nulliparity without
any gynecological symptoms.
Introduction
Endometrial carcinoma has four
histological subtypes of which the endometrioid subtype is the most common,
affecting 75–80% of patients.
Endometrioid endometrial adenocarcinoma has a better prognosis than the
other subtypes (papillary serous, clear cell or carcinosarcoma) and can
metastasize to the lung, bone, brain or liver as solitary deposits amenable to
resection.[1] Liver metastases
from endometrial cancer at the time of presentation represent true
haematogenous spread. Histopathology of typical endometrioid adenocarcinoma is usually characterize by back to back arrangement of endometrial-type of glands of varying differentiation/atypia with no intervening stroma. . Endometrioid adenocarcinoma have three grades on histopathology. Grade 1 consists of 5% or less of nonsquamous or nonmorular solid growth (well differentiated), Grade 2 consists of 6% to 50% of solid growth
( moderately differentiated) , and Grade 3 consists of more than 50% of solid growth (poorly differentiated).The various variants of endometrioid adenocarcinoma includes villoglandular, secretory, ciliated cell, and adenocarcinoma with squamous differentiation type of pattern, each having a peculiar histopathology along with the usual features of typical endometrioid adenocarcinoma.[1]
( moderately differentiated) , and Grade 3 consists of more than 50% of solid growth (poorly differentiated).The various variants of endometrioid adenocarcinoma includes villoglandular, secretory, ciliated cell, and adenocarcinoma with squamous differentiation type of pattern, each having a peculiar histopathology along with the usual features of typical endometrioid adenocarcinoma.[1]
Case
Report
A 34 year old nulliparous woman, married for 14 years,
presented to the surgery outpatient department with complaints of chronic right
sided shoulder pain for 1 year and abdominal distension for last 6 months.On
general examination she was averagely
built and nourished. Her vital parameters were stable. She attained menarche at
the age of 13 years and her past and present menstrual cycles were regular with
average amount of flow. Abdominal examination revealed distension, moderate
ascites, minimal guarding and no rigidity. A clinical impression of subacute intestinal
obstruction was made. However plain radiograph of the abdomen AP view and USG
ruled out intestinal obstruction. USG showed a cystic lesion in right lobe of
liver with moderate ascites. CT
of abdomen also showed a heterogeneous mass about 3X3 cm in the right lobe of
liver with ascites.
Ascitic fluid tapping was done. It did not show any malignant cells. CT
guided liver biopsy was done and tissue was sent for immunohistochemisty and
histopathology. Immunohistochemistry revealed expression of Cdx2 protein. Histopathological examination of the tissue
showed small fragments composed of different glands with squamous
differentiation. Hence a diagnosis of well differentiated endometrioid neoplasm
was made
and the patient was then referred to gynecology department to
rule out primary focus of malignancy. On gynecological evaluation the patient
was a case of primary infertility with history of diagnostic hysterolaparoscopy
done 6 years ago. She had taken treatment for infertility, details of which
were not available.
Her menstrual cycles were normal. She was non diabetic and non hypertensive. On
abdominal examination an infraumbilical scar of laparoscopy was present. There
was moderate ascites. On speculum examination cervix and vagina were healthy
and on bimanual examination the uterus was anteverted, bulky, soft, mobile and bilateral
fornices were free. Rectal examination showed absence of any nodularity and free
parametrium. Pap smear revealed chronic inflammation with few dysplastic cells.
Ultrasonography of pelvis revealed uterus 10×7×6 cm with thick polypoidal
endometrium of 2cm. Chest radiograph was normal. Other routine
preoperative investigations were normal. A fractional curettage was performed.
Histopathological report of the endometrial tissue was suggestive of well
differentiated endometrioid adenocarcinoma of the endometrium. Hence the
diagnosis of stage IV B carcinoma endometrium with hepatic metastasis was made.
In view of advanced carcinoma endometrium the patient was referred to an
oncology center for further treatment. She was advised cytoreductive surgery
followed by adjuvant radiotherapy. But patient did not follow up and died after
8 months from diagnosis of advanced carcinoma endometrium.
Figure 1. Histopathological appearance of the tumor. A. Low power; B. High power.
Discussion
Endometrial cancer is a disease that occurs
primarily in postmenopausal women in the sixth and seventh decades of life and is virulent with advancing age. The risk for endometrial cancer increases with unopposed estrogen. Various
conditions associated with an increased risk of endometrial carcinoma include
obesity, nulliparity, early menarche, and late menopause. Obesity appears to
pose the greatest risk due to aromatization of androstenedione to estrone in
peripheral fat. Diabetes mellitus, hypertension, high fat diet and family
history of endometrial, colon, ovarian cancer have also been implicated as
the additional risk factors for
endometrial carcinoma. Infertility and a history of irregular menses as
a result of anovulatory cycles
are also documented risk factors for developing endometrial cancer.[2] Women with endometrial carcinoma have vaginal bleeding or discharge as
the only presenting symptom in 90% of the cases and less than 5% of the women
are asymptomatic. Sometimes women may experience pelvic pressure or discomfort
due to uterine enlargement or extrauterine spread of the disease and rarely
some may present with haematometra or pyometra due to cervical stenosis which
is a poor prognostic indicator of endometrial carcinoma.[3]. In contrast to the cervix, where cytological
screening has been enormously successful in preventing cervical cancer, there
is no effective general population screening of asymptomatic women for
endometrial cancer. Endometrial carcinoma is usually detected in
asymptomatic women due to
abnormal Pap test, histopathology
of the uterine specimen removed for some other indication or abnormal finding
on
abdominal and pelvic USG or CT scan obtained for an unrelated reason as it was seen
in our case. Those women who have malignant cells on Pap
test are likely to have a more advanced stage of disease.[4]
Physical
examination does not have any positive finding, although obesity and hypertension are commonly
associated constitutional factors. Abdominal examination
does not show any abnormality, except in advanced cases in which ascites or hepatic or omental metastases may be
palpable. A detailed gynaecological examination should be
performed which includes inspection of vagina and cervix along with bimanual
rectovaginal examination to
evaluate the uterus for size and mobility, the adnexa for masses, the parametria for induration, and
the cul-de-sac for nodularity. All
patients with endometrial cancer should undergo surgical staging which
includes selective pelvic and para-aortic lymph node dissection, in addition to hysterectomy and
salpingo-oophorectomy, based on the intraoperative assessment of risk for lymph
node metastasis or other extrauterine spread. Surgical staging identifies most patients with extrauterine disease and
has a significant impact on
treatment decision. Stage IV endometrial adenocarcinoma, in which tumor
invades the bladder or rectum or extends outside the pelvis, makes up about 3%
of cases.[5,6,7] Several reports have
noted a positive impact of cytoreductive surgery on survival, the median survival being about 3 times greater with optimal cytoreduction (18–34
months versus 8-11 months, respectively).[8,9] In our case
due to noncompliance of patient her survival was reduced to 8 months.
Treatment for stage IVB endometrial cancer involves one of tumor-reduction or
palliative chemotherapy or radiation. Tumor-reductive surgery is typically
followed with adjuvant chemotherapy, hormonal therapy, and/or radiation therapy
although
radiotherapy is the treatment of choice. Resection of liver
capsule metastases as part of cytoreductive surgery has been shown to be
feasible and may prolong survival.[10] Palliative radiotherapy and
platinum-based chemotherapy regimens followed by progestogens can also be
considered in patients with endometrial carcinoma with liver metastasis which
is effective in both preventing recurrence and prolonging survival. Patients
with suspected advanced stage endometrial carcinoma should be counseled on the
potential benefits of optimal cytoreductive surgery and alternative treatment
options should be considered in those
with surgically nonresectable disease.
References
- Fanning J, Evans MC, Peter AJ, et al. Endometrial adenocarcinoma histological subtypes; clinical and pathological profile. Gynecol Oncolm1989;32:288-291.
- Brinton LA, Berman ML, Mortel R, et al. Reproductive, menstrual and medical risk factors; for endometrial cancer: results from a case control study. Am J Obstet Gynecol 1993;81:265-271.
- Smith M, McCartney AJ. Occult, high-risk endometrial carcinoma. Gynecol Oncol 1985;22:154-161.
- Dubeshter B, Warshal DP, Angel C, et al. Endometrial carcinoma: the relevance of cervical cytology. Obstet Gynecol 1991;77:458-462.
- Pliskow S, Penalver M, Averette HE. Stage III and IV endometrial carcinoma: a review of 41 cases. Gynecol Oncol 1990;38:210-215.
- Aalders JG, Abeler V, Kolstad P. Stage IV endometrial carcinoma: a clinical and histopathological study of 83 patients. Gynecol Oncol 1984;17:75-84.
- Goff BA, Goodman A, Muntz HG, et al. Surgical stage IV endometrial carcinoma: a study of 47 cases. Gynecol Oncol 1994;52:237-24.
- Bristow RE, Zerbe MJ, Rosenshein NB, et al. Stage IV endometrial carcinoma: the role of cytoreductive surgery and determinants of survival. Gynecol Oncol 2000;78:85-91.
- Chi DS, Welshinger M, Venkatraman ES, et al. The role of surgical cytoreduction in stage IV endometrial carcinoma. Gynecol Oncol 1997;67:56-60.
- Tangjitgamol S, Levenback CF, Beller U, Kavanagh JJ. Role of surgical resection for lung, liver, and central nervous system metastases in patients with gynaecological cancer: a literature review. Int J Gynecol Cancer.2004;14:399–422.
Citation
Panchbudhe
S, More
V, Mali
K, Satia
MN. Retrospective
diagnosis of advanced Carcinoma Endometrium from hepatic nodule.
JPGO 2014 Volume 1 Number 2 Available from: http://www.jpgo.org/2014/02/retrospective-diagnosis-of-advanced.html